Is It Right for You?
Starting in 2014, almost everyone should be able to get health coverage. In fact, if you don’t have a plan, you may have to pay a tax penalty. The question becomes, which plan is right for you and your family?
If you don’t qualify for AHCCCS based on your disability, you may still qualify under other AHCCCS rules and you should consider other options we will introduce, including Medicare and private health insurance.
If the Social Security Administration (SSA) or AHCCCS says you are disabled, you may have more than one way of qualifying for AHCCCS, depending on your situation.
This article focuses on whether you will qualify because you have a disability. However, just because you have a disability does not mean you will qualify for AHCCCS under the rules discussed here. You may qualify under rules discussed in another DB101 AHCCCS article or you may not qualify for AHCCCS at all, depending on your situation.
AHCCCS Basic Eligibility Requirements
To qualify for AHCCCS under the rules described in this article, you must:
- Have been determined blind or disabled according to Social Security Administration rules
- Be a U.S. citizen or have an immigration status that is eligible for AHCCCS, and
- Meet certain income requirements.
Note: If you’re on Supplemental Security Income (SSI) or SSI’s 1619(b) provisions, you will automatically qualify for AHCCCS and do not need to apply for AHCCCS separately. You do not need to worry about the qualifying rules discussed on this page. Read more in this article’s How to Sign Up page.
They’ll say you have a disability if:
- You have a physical or mental impairment or combination of impairments
- Your impairments limit your ability to work, preventing you from earning Substantial Gainful Activity ($1,070 per month or $1,800 per month if you’re blind), and
- Your condition has lasted or is expected to last for at least 12 months.
To get a disability determination, you will have to get medical documentation specified by DDSA.
Note: If you get Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) benefits due to a disability, you automatically meet this requirement. If you don’t get SSI or SSDI benefits, you’ll have to be determined disabled by DDSA.
Citizenship or Residency
If you are an undocumented immigrant, you may qualify for AHCCCS coverage for emergencies only. To learn more about this, contact your local DES/Family Assistance Administration office.
AHCCCS is for people with low incomes. The rules we’re looking at in this article are for low-income people who also have disabilities. If you are in this situation, you may qualify if your countable monthly income is at or below at least one of two income limits:
- Test 1 compares your countable income to the Federal Benefit Rate (FBR). FBR is $721 per month for an individual.
- Test 2 compares your countable income to the Federal Poverty Guidelines (FPG). 100% of FPG is $958 per month for an individual.
There are two different tests because different people with disabilities are in different situations. You do not need to be below the limit for both tests.
Note: If your income is higher than both of these income limits, you may still qualify for AHCCCS by different eligibility rules described in DB101’s other AHCCCS article or for AHCCCS Freedom to Work, if you work.
In this article, we talk about how there is a limit for how much countable income you can have and still qualify for AHCCCS. The confusing thing is that countable income is not the same as your total income (sometimes called gross income).
Making it even more confusing is that the two tests AHCCCS uses for countable income for people with disabilities use different calculations. That means that your countable income will likely be different for the two tests if you have earned income. For example, if you make $1,200 per month at your job and have no unearned income, you would have $557.50 in countable monthly income for Test 1 and $1,115 for Test 2. Because your income would be below the income limit for Test 1, you could qualify for AHCCCS, even though your income would be higher than the limit for Test 2.
Instead of calculating it out yourself, use the tool we’ve provided below to see what your countable income is.
Figuring Out Your Countable Income
To see whether your income would qualify for AHCCCS due to your disability, AHCCCS will look at the number of people in your family, the amount of earned and unearned income your family has, and whether you have Impairment Related Work Expenses (IRWEs) or Blind Work Expenses (BWEs).
If you do not have a spouse and don’t have any children under 18 living with you, use the calculator below to see whether your income is below the income limits for at least one of the two tests. Fill it out with this information:
Your monthly unearned income, including SSDI payments, Workers’ Compensation payments, cash gifts you get, and income from a trust or investments.
Do not include payments you get from TANF Cash Assistance, Section 8 housing, or Nutrition Assistance. These payments are all exempt under AHCCCS’s countable income rules.
- Your gross monthly earned income (income from work before taxes are deducted), including wages, tips, bonuses, and self-employment earnings.
- Any Impairment Related Work Expenses (IRWEs) or Blind Work Expenses (BWEs). Talk to a Work Incentive Consultant if you have any questions about this.
|Your Monthly Earned Income||$|
|Your Monthly Unearned Income||$|
|Your Monthly Impairment Related Work Expenses (IRWEs)||$|
Test 1 (FBR)
|Your countable income for Test 1|
|Your income is lower than FBR||0.00|
|Your income is higher than FBR||0.00|
Test 2 (FPG)
|Your countable income for Test 2|
|100% of FPG||$958|
|Your income is lower than 100% of FPG||0.00|
|Your income is higher than 100% of FPG||0.00|
|» You may qualify based on both tests.||0.00|
|» You may qualify based on Test 1.||0.00|
|» You may qualify based on Test 2.||0.00|
|» You don't appear to qualify.||0.00|
If you live with other people or want more exact information about your AHCCCS eligibility, try DB101’s Benefits and Work Calculator.
If you have a disability, meet residency requirements, and have countable monthly income that is below one of the income limits, you may qualify for AHCCCS by disability rules.
If your countable income is more than the limits for these tests, you may have these options:
- AHCCCS is expanding. Now, many people with and without disabilities can get it if their total income is up to 138% of the Federal Poverty Guidelines ($1321.35 per month if you’re single). Read DB101’s AHCCCS article.
- AHCCCS Freedom to Work is for people with disabilities who work. It has low monthly premiums. Read DB101’s AHCCCS Freedom to Work article.
- If your family’s income is at or below 400% of FPG, the government may help you pay for an individual insurance plan on Healthcare.gov. Read DB101’s Buying Coverage on Healthcare.gov article.
AHCCCS, Private Health Coverage, and Medicare
AHCCCS and Employer-Sponsored Health Coverage
If you qualify for AHCCCS, it will always be your best choice, even if your employer offers health insurance. That’s because AHCCCS has no monthly premium and the copayments for services are usually much lower than copayments required by employer-sponsored plans. Also, AHCCCS may cover some services that your employer-sponsored coverage does not pay for.
However, there are a couple of advantages to having both AHCCCS and employer-sponsored coverage at the same time:
- Private insurance may cover some benefits that AHCCCS doesn’t or the other way around.
- Private coverage may let you choose from more doctors.
AHCCCS and Individual Plans
If you are eligible for AHCCCS, then you will not be eligible to get government help to pay for a private insurance plan. That means the private insurance plan may be expensive for you. If you qualify for AHCCCS, it will always be a better option for you than paying for an individual plan.
AHCCCS and Medicare
There are significant advantages to this. Most importantly, if you have both:
- AHCCCS will usually pay your Part B premium (and your Part A premium, if you have one) through a Medicare Cost Sharing Package. It may also pay your Medicare deductibles, co-insurance, and copayments.
- You will automatically be enrolled in a Part D benchmark plan and automatically qualify for the Part D Low Income Subsidy. The Low Income Subsidy means you may not have to pay a premium for your Part D or any deductibles, including the donut hole. All you would pay for prescription drugs are Part D’s copayments, which range from $1.20 to $6.35.
- AHCCCS covers many more services than Medicare, so by having both you’ll have better health care coverage than you would by enrolling in just one or the other.
If you have both public and private health coverage, the private benefits will usually pay for medical expenses first, Medicare second, and AHCCCS last.
So, if you get a medical service that is covered by your private coverage, that policy pays for it. If it’s not covered by private health coverage, but is covered by both Medicare and AHCCCS, Medicare pays for it. If it’s not covered by your private coverage or Medicare, but AHCCCS does cover it, AHCCCS pays for it, as long as it’s an approved expense.
Note: If you use a health provider that is not covered by AHCCCS, AHCCCS will not pay any medical expenses. So, if your health care provider doesn’t take AHCCCS and your private insurance or Medicare won’t cover everything, AHCCCS won’t help pay the rest. Make sure to find providers who accept AHCCCS.
The Centers for Medicaid and Medicare Services has a helpful pamphlet on Medicare and Other Health Benefits: Your Guide to Who Pays First.